UNIVERSIDAD DE DAGUPAN

SCHOOL OF HEALTH SCIENCES

Arellano St., Dagupan City, Pangasinan
NURSING CARE PLAN

Name: Joyce Ann P. Peregrino, S.N Date: 04/08/2022 Inclusive Dates of Rotation: _____________
Year & Block: 2nd year / Shift/Days: ________ Clinical Instructor: ____________________________________________

Patient’s Name (Optional)/ Case Number: L. R.

NURSING DIAGNOSIS: Actual - Fatigue related to recurring Hypertension / Potential - Risk for fall related to recurring Hypertension as evidenced by fatigue
Medical Diagnosis: Hypertension
Expected Outcome: Refer to Planning Column
Target Date:

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective Actual Short term Independent Short term
 Occasional fatigue  Fatigue related to  After 1 hr. of  Define and state the  Provides basis  After 1 hr. of
recurring nursing limits of desired BP. for understanding nursing
History Hypertension interventions, the Explain elevations of BP, interventions, the
 Prehypertension client will appear hypertension and its and clarifies client appeared
 Dyslipidemia Potential relaxed and ease the effect on the heart, misconceptions and relaxed and eased
 Type 2 Diabetes  Risk for fall related fatigue she is blood vessels, also understanding the fatigue she is
to recurring experiencing. kidney, and brain. that high BP can experiencing.
Family History Hypertension as exist without
 Hypertension evidenced by  After 8 hours of symptom or even  After 8 hours of
 Type 2 Diabetes fatigue nursing when feeling well. nursing
 Myocardial interventions, the interventions, the
Infarction patient will  Assist the patient in  These risk factors patient was able to
verbalize identifying have been shown to verbalize
understanding of modifiable contribute to understanding of
the disease process risk factors like diet hypertension. the disease process
and treatment high in sodium, and treatment
regimen. saturated fats and regimen.
cholesterol.
 Long Term  Reinforce the  Lack of cooperation Long Term
 After 1 week of importance of is common reason  After 1 week of
intervention, the adhering to for failure of intervention, the
client will manifest treatment regimen antihypertensive client will manifest
wellness. And and keeping follow therapy. wellness. And
continue the self- up appointments. continue the self-
care management. care management.
 Suggest frequent  Decreases
position changes, peripheral venous
leg exercises when pooling that may be
lying down. potentiated by
vasodilators
and prolonged
sitting or standing.

 Help patient  Two years on

identify sources of moderate low salt
sodium intake. diet may be
sufficient to control
mild hypertension.

 Encourage patient  Caffeine is a

to decrease or cardiac stimulant
eliminate caffeine and may adversely
like in tea, coffee, affect cardiac
cola and chocolates. function.

 Stress importance  Alternating rest and

of accomplishing activity increase
daily rest periods. tolerance to
Dependent activity progression.
 Give due
medications as
ordered by the  Refer to drug study
physician.

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Patient/ Significant Other’s Signature Student Nurse’s Signature